Regular Article

Psychother Psychosom 2013;82:161169 DOI: 10.1159/000345968

Received: May 27, 2012 Accepted after revision: November 15, 2012 Published online: March 27, 2013

Clinician-Identified Depression in Community Settings: Concordance with Structured-Interview Diagnoses

Ramin Mojtabai
Department of Mental Health, Bloomberg School of Public Health and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Md., USA

Key Words Depression Diagnosis Primary care

Abstract Background: Relatively little is known about the prevalence and correlates of overdiagnosis of depression in community settings. This study examined the extent to which individuals with clinician-identified depression in the community meet the criteria for DSM-IV major depressive episodes (MDE) and characteristics of these individuals. Methods: In a sample of 5,639 participants with clinician-identified depression drawn from the 20092010 United States National Survey of Drug Use and Health, the proportion of participants who met the 12-month MDE criteria, ascertained by a structured interview, and variations in MDE diagnosis across different groups of participants were examined. Mental health profiles and service use of participants who met the MDE criteria were compared to those who did not meet these criteria. Results: Only 38.4% of participants with 12-month clinician-identified depression met the 12-month MDE criteria. Older adults were less likely than younger adults to meet the criteria only 14.3% of those 65 years old or older met the criteria, whereas participants with more

education and those with poorer overall health were more likely to meet the criteria. Participants who did not meet the 12-month MDE criteria reported less distress and impairment in role functioning and used fewer services. A majority of both groups, however, were prescribed and used psychiatric medications. Conclusions: Depression overdiagnosis and overtreatment is common in community settings in the USA. There is a need for improved targeting of diagnosis and treatments of depression and other mental disorders in these settings. Copyright 2013 S. Karger AG, Basel

Introduction

Diagnosis and treatment of depression in general medical settings has received much research attention over the years [1, 2]. However, this research has mainly focused on underdiagnosis and undertreatment of depression [112]. Less research attention has focused on the problem of overdiagnosis and overtreatment of depression, which is at least as common as underdiagnosis and undertreatment [2]. A study that compared Italian primary care physicians clinical diagnoses with diagnoRamin Mojtabai, MD Department of Mental Health, Johns Hopkins Bloomberg School of Public Health 624 North Broadway, Hampton House/Room 797 Baltimore, MD 21205 (USA) E-Mail rmojtaba@jhsph.edu

2013 S. Karger AG, Basel 00333190/13/08230161$38.00/0 E-Mail karger@karger.com www.karger.com/pps

ses based on the WHO ICD-10 found that 45% of patients labeled as depressed by primary care physicians did not meet the ICD-10 criteria [13]. Almost 30% of these patients diagnosed in 1996 were prescribed an antidepressant. The rapid growth of antidepressant medication treatment in more recent years [1417] and the increasing recognition of the health [18, 19] and economic consequences [20] of this trend call for continued monitoring of overdiagnosis and overtreatment of depression and other psychiatric disorders in community settings [21]. The present study explored the correspondence between depression as identified by clinicians and communicated to the patients (henceforth called clinician-identified depression) and structured interview results based on DSM-IV criteria in recent samples of adults drawn from the general population of the United States. More specifically, the study examined the prevalence of DSMIV 12-month major depressive episodes (MDE) among individuals with a clinician-identified depression. The study further explored variations in MDE diagnosis across different groups of participants and compared mental health profiles and service use, including psychiatric medication use, among participants with clinicianidentified depression who did or did not meet the 12-month MDE criteria.

Methods
Sample The sample was drawn from the adult participants in 2 consecutive years of the cross-sectional National Survey of Drug Use and Health (NSDUH) conducted in 2009 and 2010. The NSDUH sample has been described in detail elsewhere [22, 23]. Briefly, NSDUH is an annual survey of civilians 12 years old or older in the 50 states and the District of Columbia sponsored by Substance Abuse and Mental Health Services Administration. The sample for this study was further limited to adults as the questions regarding mental health service use were only asked from this age group. All interviews were conducted in person, using computerassisted interviewing methods (response rates 75.7 and 74.7%, respectively). The sample for this study comprised 5,639 (7.2%) of the 75,758 adult participants of the NSDUH 20092010 with 12-month clinician-identified depression who completed the structured interview for depression. Assessments Clinician-identified depression was assessed by asking the participants to select from a list those conditions that they were told they had by a doctor or other medical professional. Participants were next asked to identify conditions that they were told they had in the past 12 months. Participants who identified de-

pression on these lists were categorized as having 12-month clinician-identified depression. MDE in the past 12 months and over the lifetime were assessed using a structured interview based on the DSM-IV criteria. Questions were adapted from the Composite International Diagnostic Interview (CIDI) used in the National Comorbidity Survey Replication [24]. To meet the MDE criteria, the participant had to meet 5 out of the 9 symptom criteria and the DSMIV clinical significance criteria (i.e., distress or impairment in functioning). One of the criteria had to be either depressed mood or markedly diminished interest or pleasure in daily activities (stem questions). The psychometric properties of the NSDUH major depression module have not been examined. However, the CIDI module for MDE, on which the NSDUH interview is based, has demonstrated acceptable reliability (test-retest kappa: 0.620.66; interrater reliability kappa: 9397) [25]. Lifetime minor depression was defined by the presence of at least 2 DSM-IV MDE symptoms including at least 1 of the stem questions for a period of 2 weeks or longer [2628]. Probable serious mental illness was assessed using the K6 screening instrument and a modified version of the World Health Organization Disability Assessment Scale (WHODAS) [2932]. K6 is a 6-item measure of psychological distress. Participants were first asked about complaints in the past 30 days. Next, they were asked if there was a month in the past year when they felt more depressed, anxious, or emotionally stressed than in the past 30 days. Participants who reported any of the K6 symptoms were asked the 13 WHODAS questions regarding impairment in social, occupational and cognitive functioning. In a clinical reappraisal study involving 1,506 adult NSDUH 2008 participants [3335], K6 and WHODAS were calibrated for predicting DSM-IV mental disorders (including past year mood, anxiety, psychotic, eating, impulse control, substance use and adjustment disorders) ascertained by the Structured Clinical Interview for DSM-IV (SCID) [36] and Global Assessment of Functioning (GAF) scale [37, 38]. Using a regression model based on this calibration study, probable mild (SCID diagnosis and GAF >59), moderate (SCID diagnosis and GAF = 5159) and severe mental illness (SCID diagnosis and GAF <51) were identified by NSDUH investigators. The steps in deriving these predicted probabilities and their validity are detailed elsewhere [33]. Suicidal ideations and attempts were assessed for the past 12 months. Mental health treatment seeking was ascertained by asking about inpatient and outpatient services in the past 12 months. In addition, the setting of care and number of visits (up to 30 in the past 12 months) were recorded for outpatient visits and partial day hospitals. Participants were also asked if they had taken prescription medications to treat a mental or emotional condition in the past 12 months. In addition, sociodemographic and health characteristics of the participants were recorded. These included: sex, age, race ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), employment (working, unemployed, not in workforce), marital status (married or living as married, widowed, divorced or separated, never married), family income (USD <20,000, 20,000 39,999, 40,00074,999, +75,000), self-rating of overall health (from excellent to poor), and the number of chronic physical illnesses (from 0 to 3+). The rating of physical illnesses was based

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on questions about clinician-identified asthma, bronchitis, cirrhosis, diabetes, heart disease, hepatitis, lung cancer, HIV, pneumonia, stroke or ulcer in the past 12 months. Analysis Analyses were conducted in three stages. First, in the sample of participants with clinician-identified depression, the proportion who met the criteria for 12-month MDE was computed and compared across groups defined by sociodemographic and health characteristics. Second, to assess the psychiatric profiles of individuals who were identified by clinicians as depressed but who did not meet the 12-month MDE criteria, the prevalence of probable serious mental illness, suicidal ideation and suicide attempts in this groups of participants was compared with participants who met the 12-month MDE criteria. Third, mental health service use, treatment settings, number of mental health visits and prescription medication use were compared among participants who did or did not meet the 12-month MDE criteria. Analyses were conducted using Stata 12 software [39] and adjusted for the complex sampling design of the NSDUH. All percentages were weighted by sampling weights. A p value of <0.05 was used to determine statistical significance.

Participants who met the 12-month MDE criteria were significantly more likely than those who did not meet these criteria to score on K6 and WHODAS in a range consistent with a probable DSM-IV mental illness. Over 60% of those who met the 12-month MDE criteria were categorized as experiencing probable severe mental illness compared to 14% of those who did not meet the 12-month MDE criteria. Participants who met the MDE criteria were also significantly more likely to report suicidal ideations and suicide attempts (table2). Past Year Mental Health Treatments and Prescription Medication Use Participants with 12-month clinician-identified depression who met the 12-month MDE criteria were more likely than those who did not meet the criteria to use both inpatient and outpatient mental health treatments and prescription medications (table2). However, a majority of both groups reported having used prescription medications. This pattern persisted even after excluding participants who met the criteria for lifetime major and minor depression: of 1,904 such participants with clinician-identified depression, 1,279 (69.4%) reported having used prescription medications. There were few differences among participants who did or did not meet the 12-month MDE criteria with regard to outpatient treatment setting. However, participants who met the 12-month MDE criteria were significantly more likely to use outpatient services in more than one setting compared to those who did not meet the 12-month MDE criteria (25.9 vs. 13.5%, odds ratio = 2.25, 95% confidence interval = 1.673.03, p < 0.001) and to have had a larger total number of mental health visits (mean number of visits 13.3 vs. 9.8, regression coefficient = 3.54, standard error = 0.87, p < 0.001).

Results

Prevalence of 12-Month MDE Overall and across Sociodemographic and Health Groups Only 2,309 (38.4%) of the 5,639 participants with 12-month clinician-identified depression met the 12-month MDE criteria. Participants who met the MDE criteria varied considerably from those who did not meet these criteria with regard to sociodemographic and health characteristics (table1). In multivariate analyses, participants in the age groups 3549 and 65+ years were less likely than those in the 18- to 25-year group to meet the 12-month MDE criteria. Only 14.3% of participants aged 65+ years with a clinician-identified depression met the 12-month MDE criteria. In contrast, participants who were out of the workforce, those who were divorced or separated, the more educated and those with poorer self-rated health were more likely to meet the 12-month MDE criteria (table1). Mental Health Profiles A total of 753 (23.2%) of the 3,330 participants with a 12-month clinician-identified depression who did not meet the 12-month MDE criteria met the life-time MDE criteria. Of the remaining 2,577 participants, 669 (24.1%) met the criteria for lifetime minor depression. Overall, 1,422 (42.7%) of the 3,330 who did not meet the 12-month MDE criteria met the criteria for either lifetime MDE or minor depression.
Clinician-Identified Depression

Discussion

There were three main findings in this study. First, only 38.4% of community-dwelling adults with clinician-identified 12-month depression met the criteria for 12-month MDE. Slightly more than 40% of those who did not meet the criteria for 12-month MDE either met the criteria for lifetime MDE, or had minor depression. Overall, 64.1% (n = 3,731) of the 5,639 of participants with clinician-identified 12-month depression had depressive symptoms some time in their life. Individuals who did not meet the 12-month MDE criteria were sigPsychother Psychosom 2013;82:161169 DOI: 10.1159/000345968

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Table 1. Characteristics of participants who were told in the past 12 months by a clinician that they had depression and who did or did

not meet the criteria for 12month MDE in the NSDUH, 20092010 Characteristics Total number Met the criteria for MDE n Total group Sex Female Male Age groups 1825 2634 3549 5064 65+ Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Other Employment Working Unemployed Not in the workforce Marital status Married/living as married Widowed Divorced/separated Never married Years of education <12 12 >12 Family income (USD per year) <20,000 20,00039,999 40,00074,999 +75,000 Self-rating of overall health Excellent Very good Good Fair Poor Number of chronic physical illnesses 0 1 2 3+ 5,639 4,100 1,539 2,435 912 1,449 664 179 4,351 365 550 373 3,200 579 1,860 1,911 146 914 2,668 933 1,815 2,891 1,686 1,912 820 431 711 1,842 1,827 953 306 3,743 1,273 409 214 Row % Did not meet the criteria for MDE n 3,330 2,382 948 1,398 535 852 394 151 2,590 207 323 210 1,975 328 1,027 1,219 102 479 1,530 580 1,093 1,657 911 1,145 484 790 469 1,145 1,066 515 135 2,220 752 237 121 Row % 61.6 62.2 60.2 57.2 58.1 61.3 57.5 85.7 62.3 60.7 58.4 57.5 64.7 55.9 58.5 65.4 71.6 55.6 58.0 65.7 62.5 60.1 56.2 61.8 58.9 67.9 72.7 65.0 61.4 56.3 48.1 62.3 60.5 63.3 58.0 Bivariate comparison OR (95% CI) 1.00 1.09 (0.891.34) 1.00 0.96 (0.781.20) 0.84 (0.711.00) 0.99 (0.771.27) 0.22 (0.120.40)*** 1.00 1.07 (0.801.43) 1.17 (0.871.59) 1.22 (0.742.01) 1.00 1.45 (1.091.91)* 1.30 (1.091.55)** 1.00 0.75 (0.431.31) 1.51 (1.191.92)** 1.37 (1.131.66)** 1.00 1.15 (0.891.48) 1.27 (0.991.63) 1.00 0.79 (0.640.98)* 0.89 (0.691.15) 0.61 (0.470.78)*** 1.00 1.43 (1.051.94)* 1.66 (1.242.25)** 2.07 (1.522.81)*** 2.86 (1.934.24)*** 1.00 1.08 (0.861.36) 0.96 (0.681.36) 1.20 (0.831.73) Multivariate comparison AOR (95% CI) 1.00 1.03 (0.831.29) 1.00 0.90 (0.721.14) 0.77 (0.620.96)* 0.77 (0.571.03) 0.16 (0.080.32)*** 1.00 0.90 (0.661.22) 1.05 (0.731.50) 1.11 (0.641.91) 1.00 1.32 (1.001.75) 1.47 (1.191.80)*** 1.00 0.95 (0.551.64) 1.33 (1.021.74)* 1.06 (0.831.34) 1.00 1.34 (1.041.72)* 1.72 (1.342.20)*** 1.00 0.98 (0.771.25) 1.10 (0.841.44) 0.77 (0.571.05) 1.00 1.47 (1.091.96)* 1.75 (1.302.36)*** 2.11 (1.492.97)*** 2.83 (1.754.58)*** 1.00 1.01 (0.801.28) 0.90 (0.621.33) 0.94 (0.621.44)

2,309 38.4 1,718 37.8 591 39.8 1,037 377 597 270 28 1,761 158 227 163 42.8 41.9 38.7 42.5 14.3 37.8 39.3 41.6 42.5

1,225 35.3 251 44.1 833 41.5 692 44 435 1,138 34.6 28.5 44.5 42.0

353 34.3 722 37.5 1,234 39.9 775 767 336 431 242 697 761 438 171 1,523 521 172 93 43.9 38.2 41.1 32.1 27.3 35.0 38.6 43.7 51.9 37.7 39.6 36.7 42.1

OR = Odds ratio; AOR = adjusted odds ratio; CI = confidence interval. * p < 0.05; ** p < 0.001; *** p < 0.001.

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Table 2. Mental health profiles and treatment seeking of participants who were told in the past 12 months by a clinician that they had depression and who did or did not meet the criteria for 12-month MDE in the NSDUH, 20092010
Characteristics Total number Met criteria for 12-month MDE n Column % 2,309 100 Did not meet criteria for 12month MDE n Column % 3,330 1,291 941 489 609 1,342 342 70 778 2,543 100 45.9 26.9 13.2 14.0 90.6 8.4 1.0 22.5 77.5 Bivariate comparison OR (95% CI) 1.00 (ref.) 5.62 (3.618.76)*** 11.28 (7.1217.87)*** 37.89 (24.5758.45)*** 1.00 (ref.) 5.05 (3.906.54)*** 7.05 (4.4011.28)*** 1.00 (ref.) 2.46 (1.923.16)*** 3.46 (2.414.97)*** 2.68 (2.223.23)*** 1.93 (1.522.44)*** Multivariate comparison AOR (95% CI)a 1.00 (ref.) 5.61 (3.678.57)*** 10.77 (6.9016.81)*** 36.11 (23.7554.89)*** 1.00 (ref.) 5.00 (3.926.37)*** 6.56 (4.0610.60)*** 1.00 (ref.) 2.53 (1.953.28)*** 2.92 (2.044.20)*** 2.59 (2.123.14)*** 2.01 (1.582.55)*** 1.09 (0.801.50) 1.24 (0.951.63) 1.31 (0.941.82) 1.05 (0.641.73) 1.13 (0.522.49)

Total group

5,639

Probable serious mental illness (K6/WHODAS) 1,364 None 1,298 Mild 887 Moderate 2,090 Severe 12month suicidal ideation or attempt None Ideations but no attempts Ideations and attempts 12month mental health treatment None Any 4,251 1,085 277 1,098 4,528

73 5.2 357 17.2 398 16.9 1,481 60.6 2,909 64.6 743 30.2 207 5.2 320 10.5 1,985 89.5

Type of mental health treatments among those with any 12-month mental health treatmentb Inpatient 316 204 6.8 112 2.1 Outpatient 2,549 1,313 58.6 1,236 34.6 Prescription medications 4,185 1,823 84.3 2,362 73.5

Setting of outpatient mental health treatment among those with any outpatient mental health treatment (n = 2,549)b 1.29 (0.951.75) 23.7 Outpatient mental health clinic or center 733 315 418 28.6 Private office of mental health provider 1.10 (0.861.42) 52.7 not part of a clinic 644 727 55.2 1,371 1.24 (0.911.71) 23.3 Dr.s office not part of a clinic 279 300 27.4 579 1.08 (0.611.88) 7.9 Outpatient medical clinic 94 118 8.4 212 1.28 (0.632.62) 2.4 Partial day hospital or day treatment 34 47 3.0 81

OR = Odds ratio; AOR = adjusted odds ratio; CI = confidence interval. * p < 0.05; ** p < 0.001; *** p < 0.001. a From multivariate logistic regression model adjusting for sex, age, race/ethnicity, employment, marital status, education and family income. bNumbers add up to more than the total number as participants could report multiple types of treatment or treatment in multiple settings.

nificantly less distressed and impaired than those who did meet these criteria. The estimate of false-positive rates of diagnosis of depression in this study is remarkably similar to those reported in prior studies comparing clinician diagnoses with research diagnoses [2]. A number of factors likely contribute to the high false-positive rate of depression diagnosis in community settings, including the relatively low prevalence of depression in these settings, clinicians uncertainty about the diagnostic criteria [40] and ambiguity regarding subthreshold syndromes [41]. A number of strategies have been introduced to overcome these
Clinician-Identified Depression

problems and improve the accuracy of depression diagnosis in general medical settings, including the use of multiple assessments [42, 43] and simplified diagnostic criteria [44]. There have also been calls for adoption of dimensional diagnoses [4547]. However, many general medical providers do not have the time or resources for multiple assessments and the clinical implications of dimensional measures of depression are not clear [47]. A second finding of the study was the considerable variation across population groups with regard to meeting the diagnostic criteria. Most notably, more than 6 out of every 7 participants aged 65+ years with cliniPsychother Psychosom 2013;82:161169 DOI: 10.1159/000345968

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cian-identified depression did not meet the 12-month MDE criteria. These variations can be partly explained by variations in prevalence of mood disorders in different population groups. Major depression is less common in older adults than younger adults [48], whereas it is more common in individuals with poor physical health [49]. Low prevalence can increase the number of false positive cases. Furthermore, some of the complaints of older adults and individuals with poor physical health may be misinterpreted as depressive symptoms [15]. The findings with regard to the association of education with diagnosis is intriguing especially since depression is more common in socioeconomically disadvantaged population groups [50]. It is possible that greater health literacy associated with education leads to more accurate reporting of symptoms [51]. A third notable finding of the study was the high prevalence of prescription medication treatment among individuals with clinician-identified depression. While participants who did not meet the 12-month MDE criteria used significantly fewer services and treatment contacts than those who did meet the criteria, the majority of both groups used prescription psychiatric medications. Even among participants without lifetime history of major or minor depression more than two thirds reported having taken prescription psychiatric medications. This finding highlights the growing trends in prescription and use of psychiatric medications, and especially antidepressants, in the USA [14, 16, 17, 52, 53], even in the absence of a psychiatric diagnosis [16, 54, 55]. While some of these individuals may suffer from mild or subthreshold mental health problems, little evidence supports the benefits of antidepressants in these cases [5657]. Even in patients with major depression, the benefits of treatment in routine treatment settings fall short of those reported in randomized clinical trials [58]. Inappropriate use of antidepressant medications is especially of concern in the older adults who are prone to drugdrug interactions [5962]. Over the years, a number of strategies aimed at improved targeting of psychiatric treatments in general medical settings have been proposed [6365]. Most recently, Batstra and Frances [66] proposed a stepped approach which allows clinicians to avoid labeling subthreshold symptoms and mild conditions with psychiatric diagnoses and encourages watchful waiting and the use of low-intensity psychological interventions when appropriate. Consistent with this approach, a recent initiative in the UK seeks to increase access to
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treatments recommended by the National Institute for Health and Clinical Excellence [67] for persistent subthreshold depressive symptoms and mild depression in primary care settings [68]. These efforts, however, would have to compete with the ever present pharmaceutical marketing efforts and the growing public acceptance of pharmaceutical solutions for personal and social problems [69]. The results of this study should be interpreted in the context of its limitations. First, many clinicians do not share their diagnostic impressions with their patients [70]. Thus, the rate of participant-reported clinician diagnoses is likely an underestimate of the true prevalence of the clinician diagnoses of depression in the community. Second, the correspondence between lay-administered structured interviews and clinician diagnoses is bounded by the imperfect sensitivity of these measures. In past research, lay-administered structured interviews for depressive disorders had sensitivities in the 6769% range when compared against the gold standard of clinician-administered semi-structured interviews [71, 72]. However, these numbers are much larger than the 38.4% obtained in this study. Third, the NSDUH did not ascertain the type of doctor or other medical professional. However, in community settings, mental health contacts with general medical providers are more common than contacts with specialty sector providers [73] and the general medical providers prescribe most of the antidepressant medications [16]. Fourth, many of the individuals with clinician-identified depression may in fact have other common mental disorders such as anxiety disorders, adjustment disorder or depressive disorder, not otherwise specified, which require clinical attention [74]. Some of these cases may benefit from antidepressant medication treatment [75]. The NSDUH did not assess these disorders. However, the K6/WHODAS screening for probable serious mental illness was calibrated against a broad range of mental disorders including some of these conditions. Fifth, some patients with major depression require prolonged treatment after remission of symptoms to prevent recurrence. However, almost half of patients with a first MDE experience no recurrences [76] and prolonged antidepressant treatment has been a major driver of increased volume of antidepressant use in some settings [77]. In the context of these limitations, the findings from this study highlight the challenge of diagnosis and treatment of depression and other mental disorders in community settings. With the predicted expansion of the role of primary care in management of common mental disMojtabai

orders under the upcoming health care reform in the USA [78], finding approaches to improve the accuracy of psychiatric diagnoses in these settings gains increasing urgency.

Disclosure Statement
Dr. Mojtabai has received consulting fees from Lundbeck pharmaceuticals.

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